Archer A. Associates, Inc. - Insurance Agents and Brokers
Small Business Quote
General Information
Contact Name *
Email *
Business Name
Address *
Street Address
Address Line 2
City State / Province / Region
Postal / Zip Code

Country

Business Phone *
### - ### - ####  
FAX
### - ### - ####  
Current Insurance Company
...not agency
Company Name
Policy Expiration Date
MM / DD / YYYY  
Current Insurance Coverages
Current Coverages
Bond
Commercial Auto
Commercial Liability
Commercial Property
Commercial Umbrella
Directors & Officers Liability
Disability
Group Health
Grouy Life
Professional Liability
Workers’ Compensation
Other:
Buesiness Information
# of Full-Time Employees
# of Part-Time Employees
How long in business? (yrs)
How many locations?
Please give a brief description of your business and clientele.

Property/Premesis Information
Address
Street Address
Address Line 2
City State / Province / Region
Postal / Zip Code

Country

Occupancy Status
Owner
Tenant
Years Built
% Occupied
Sprinklers
Yes
No
Construction Type
Stories
# Basements
Sq. Footage
Burglar Alarm
Yes
No
Building Value
Contents
Other Property (specify)

Insurance Information
Other
Annual Gross Sales: (before taxes:)
Number of Employees
Annualized Payroll
Cost of any Subcontracted Work
Limits Requested
$300,000
$500,000
$1,000,000
$2,000,000
Describe any claims you’ve had in the past 5 years.

Additional Comments

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